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Case Pres With NCP @ Pnp

Case Pres With NCP @ Pnp



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Published by sitaw

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Categories:Types, School Work
Published by: sitaw on Apr 23, 2009
Copyright:Attribution Non-commercial


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BSN048GROUP 190-BRieza, Wendy Ann M.Salamat, Neoma Syrilla T.Santos, Janessa Joy S.Prof. Jeannie Patrimonio
 The client chosen for this case is R.T.C NORD, female, 26 years of age,. Her religion is Roman Catholic She wasborn on July 24, 1981 in Tuguegarao City. And married to PO1 T.C PNPSAF B96L28 from Paliparan Dasma, Cavite.Admitted to OBward by admitting officer/ admitting physician PSUPT Guiatani on 21 2330H July 2008, roomnumber 3 with hospital no. 04-01-35. Is Dependent, ambulatory, First type of admission with Direct source of Admission. Has admitting Diagnosis of G2P1 PU 23 4/7 weeks AOG, Pre Term Labor. R.T.C is accompanied by husbandwith cc of vaginal spotting or verbalized. LmP is February 22, 2008, EDC is November 29, 2008, RR of 21 cycles/min,BP 130/80mmhg with temp of 36.7 and cardiac rate of 78bpm.Conscious and coherent, with negative uterinecontraction and positive on vaginal spotting.We chose this case because this case is more challenging among other cases that we’ve handled and there’sa lot to learn from this case. In addition to that, the diagnosis of the patient might be a threat to the fetus that needsto be focused on, assessed for nursing intervention to help prevent further complications.
II Nursing HistoryA.Past health History
R.T.C 26 y/o G2P1 doesn’t have history on Hypertension, Diabetes mellitus, and asthma. She is diagnosed of hyperthyroidism during her first pregnancy on the year 2006 on PTV but stop after several weeks.B
. History of Present Illness
R.T.C was admitted dependent, ambulatory, PU 23 4/7 weeks of AOG, Pre Term Labor. Consulted regardingthyroid problem, still for follow up of FT3 FT4 TSH. Undergone Transabdominal Ultrasound result revealedoligohyramnios (AFI- 1.7cm).
Discharge PlanMedication:
Isoxsuprine tablet Q8HInderal 10mg 1 tab BIDMV (natalbes) tablet ODFC Fumirate tab (fumuim) OD
-rest and sleep-medication-increase fluid intake
Health Teaching:
Low levels of amniotic fluid can increase your risk of complications during labor. The main concern is that the fluid level will get solow that your baby's movements or your contractions will compress the umbilical cord. So
Oligohydramnios can sometimes betreated withbed rest, oral and intravenoushydration,antibiotics,steroids, and amnioinfusion. It is advised to continue the increse of oral fluids, have bed rest and consult doctor as advised.
Out Patient:
-The patient should consult doctor/physician if there are complications after discharge for immediate action.

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